Pills for Cheap

Appendicitis is an inflammation (infection) of the appendix. The appendix is a hollow tube about the size of your little finger that forms a blind pouch where the small intestine joins the large intestine. In 99 percent of all children, the appendix lies in the lower right quarter of the child’s abdomen.

Appendicitis can occur at any age. If the appendix is not surgically removed, the infection worsens until the appendix bursts. Then the infection spreads throughout the abdomen. An infected appendix may perforate (rupture) within hours of the initial pain or may not rupture for a day or two. A ruptured appendix can lead to death.

Signs and symptoms

Persistent abdominal pain in your child should be considered a symptom of appendicitis until proven otherwise. Typically, the pain of appendicitis is constant; it does not come and go as does the pain from cramps. Once it starts, it grows continually worse. The pain may start in the pit of the stomach, but it usually soon moves to the lower right quarter of the abdomen. The pain is made worse by walking or just moving about. The abdomen is tender to a gentle pressure in the lower right quarter, more tender than in other areas. There may be nausea and vomiting, but these symptoms usually start only after the pain has started.

Generally, there is a low-grade fever (37.8°C, oral; 38.3°C, rectal), but the temperature may range anywhere from normal to 40°C. Bowel movements are usually normal, but there may be diarrhea. Diagnosis is difficult because all of these signs may not be present. Because diagnosis is so difficult and the condition is so serious, call your doctor if you have any reason to suspect appendicitis.

Home care

Try applying gentle heat, as with a heating pad turned to “low.” If pain gets worse, it is probably appendicitis. Never apply cold; this can mask the symptoms of appendicitis.

Do not give pain killers such as paregoric or codeine. Acetaminophen is safe but useless. Aspirin can affect the blood’s ability to clot, so it should not be given in case the child needs surgery. Allow only clear liquids by mouth. However, once you suspect that there is a strong possibility of appendicitis, do not give your child any food or drink until you consult your physician. Never give a laxative or enema.

Precaution

If pain persists in the lower right quarter of the abdomen, despite home treatment measures, call your doctor.

Medical treatment

The only acceptable treatment for appendicitis is surgical removal of the appendix (an appendectomy). Therefore, your doctor must be reasonably sure of the diagnosis. In addition to the abdomen, your child’s chest and throat will be examined because a throat infection and pneumonia can cause symptoms of appendicitis. A rectal examination will also be performed and a blood count and a urinalysis done. (These last two tests do not prove or disprove appendicitis, however.) An X ray may be called for.

Once tests are complete, your doctor may operate or admit your child to a hospital to watch the child for a few hours until the diagnosis becomes more certain. Unnecessary surgery is to be avoided, but the rule of safety is to operate on a child who may have appendicitis rather than postpone surgery until the appendix ruptures.

*16/84/5*

Comic actor John Candy. Professional baseball player Nolan Ryan. At age 43, both hit milestones in their lives. One had just pitched two no-hitters, putting the finishing touches on a glorious major-league career that spanned 27 years. The other smoked and had a weight problem and was dead of a heart attack. Sometimes our destiny isn’t in our hands. But sometimes it is.

Lots of guys point their fingers at the fates when talking about their health, says Walter M. Bortz II, M.D., clinical associate professor of medicine at Stanford University School of Medicine and author of Dare to Be 100. Or worse, they believe that coming from “good stock” gives them license for self-abuse. The truth is that our genes generally have less to do with how long we live than we’d like to believe, says Dr. Bortz. “Genetics have about a 20 percent influence on life span,” he says. “The rest is in your hands.”

“The length of your life is hugely affected by your lifestyle,” agrees Dr. George Webster, researcher in molecular biology and aging. “Lots of people today are living a hell of a long time because they’re finally doing what they ought to be doing-not smoking, getting out of their chairs, and becoming more active.” Here are the top seven behaviors experts say will shorten your life and what you can do about them.

The Meat-and-Potato Men

Sixty-nine percent of men admit that they struggle with eating a balanced diet. Most of us eat about 10 percent more than the 30-percent-calories-from-fat-a-day plan we’re supposed to stick to. We’re eating a measly three or four servings of fruits and vegetables each day instead of the five to nine the U.S. Department of Agriculture Food Guide Pyramid recommends. And about one-third of men are overweight. “Then we’re surprised when our health gives out,” Dr. Webster says.

“We need to and can do much better,” says Ken Goldberg, M.D., founder and director of the Male Health Institute in Dallas and author of How Men Can Live As Long As Women. “The key is to follow a healthy diet most of the time, so you can have nachos and beer at the ball game and it won’t matter.” Here’s what experts recommend.

Eat just one. If each time you eat, you include a fruit or a vegetable, you’ll steadily improve your health, says Dr. Goldberg. The 30-year Framingham Heart Study by Harvard researchers found that with each additional serving of fruits and vegetables that 832 men ages 45 to 65 ate, the lower their risk of stroke became. And that’s only one benefit. Eating more fruits and vegetables also lowers your risk for colon cancer and heart disease, adds Dr. Goldberg.

Get the red out. When faced with a choice in meats, choose fish, turkey, or chicken, Dr. Goldberg says. A landmark study of close to 48,000 male health professionals found that men who ate the most red meat had a significantly higher risk for advanced prostate cancer than those who ate the least.

Stop, drop, and live. A side benefit of eating more fruits and vegetables and less fatty red meat is that you’ll also likely shed a few pounds, says Dr. Goldberg. Even the least bit of waist-whittling can add to your life. In another landmark, 22-year study of nearly 20,000 men, researchers found that being just 2 to 6 percent over your ideal weight increases your risk for cardiovascular disease. Being as much as 20 percent over increases your risk by more than 2Ó2 times that of ideal-weight men.

*8/36/5*

Case 1

A grossly obese 41 year old male was admitted to hospital for knee surgery. He lived alone in a small unit, was unemployed, had no interest in outdoor activities or hobbies and had very poor dietary habits. At 180 Kg, with high blood pressure and a failing heart he was not a good candidate for anesthesia. It was decided to seek the opinion of a respiratory specialist when nursing staff and fellow inpatients complained of his loud and unrestrained snoring and it was with obvious relief that he was transferred to the sleep unit. Overnight studies demonstrated severe sleep apnoea with both obstructive and central components. He was fitted with a nasal CPAP mask which greatly improved his nocturnal oxygenation but surgery was still considered too great a risk for such a patient. He was advised to continue nasal CPAP at night for the remainder of his time in hospital to familiarize himself with the procedure for home use. He was discharged from hospital following a thorough assessment of his heart disease and blood pressure, and placed on a strict weight reduction diet. The man was seen a month later in an outpatient clinic. He had reverted to his previous eating habits, put back on the small amount of weight lost during hospitalization and had discontinued the use of CPAP. He could not be convinced of its benefits and remains untreated for this serious condition.

Comment: An unmotivated patient with this sort of medical history can only expect further deterioration. It takes some time to become accustomed to CPAP, but failing that there should at least be an urgent reappraisal of one’s lifestyle.

Case 1

After many years of recurring tonsillitis in a 7 year old girl, her parents had reached the point of desperation. This first manifested itself as snoring when the child was about 18 months old but a pediatrician assured the parents that the young girl would eventually grow into her large tonsils. Sleep related snoring and occasional episodes of tonsillitis marked the early years of her life until she was 4 years old when her mother became aware of times when the child seemed to be struggling for breath. In retrospect, judging by a description of events in the following years, the child had developed OSA, the consequences of which were to disrupt the life of parents and child for a further three years. Severity of the child’s airway obstruction no doubt reflected the status of the child’s tonsils. At best there was always a degree of snoring but a common cold or any inflammation of her tonsils would guarantee a succession of traumatic nights; traumatic for the child who would awake several times a night crying and further complicated by instances of bed-wetting and falling out of bed. It was also traumatic for the parents who were anxious about their daughter’s distress at night, not to mention the considerable disruption to their own sleep. Antibiotics probably helped to minimize the duration of these episodes but it was becoming increasingly clear that prescription of these medications was not addressing the underlying problem.

For a girl of above average ability, she was not progressing as well as could be expected and frustrated teachers would report on her tiredness and lack of application. The parents finally sought help from a pediatrician with some expertise in sleep apnoea. A hospital admission and overnight studies documented airway obstruction and oxygen desaturation consistent with OSA. Tonsils and adenoids were surgically removed a month later and the results were immediately apparent. Snoring was virtually abolished and her parents no longer had to comfort a distressed child at night, indicating an improvement in sleep quality and although she still experiences occasional colds and upper respiratory tract infections, heavy snoring and complete airway obstruction has never reoccurred.

Comment: Disruption of home and school life could have been avoided with earlier detection of OSA.

*16/51/5*

Preventive medicine can be divided into three categories.

Primary prevention involves the removal of causes so that the condition doesn’t occur in the first place. Diseases related to smoking are obvious examples here: stop people smoking (primary prevention) and the smoking-related diseases disappear.

Secondary prevention picks up disease before symptoms occur. This is the essence of health screening which, by detecting disease early, can prevent the development of more serious manifestations of the disease. Detecting previously undiagnosed high blood pressure is a good example of this kind of prevention.

Tertiary prevention involves the management of diagnosed disease in such a way as to prevent or limit the development of a disability or to prevent the person dying prematurely. The best example here is diabetes. Diabetics with good tertiary prevention can now live long and near-normal lives.

But what are we aiming for with all the prevention-eternal life? No. Most people, when asked, are happy to settle for a reasonably long lifespan spent in good health. In simple terms medicine over the last hundred years or so has shifted deaths in early years to later life. However, despite a four-fold increase over the last century in the number of men living to be 100 and a nine-fold increase in the number of women living to that age, the proportion is still only one in 1,000 and 5 in 100 respectively. Suggestions that we could all live to 130 or more are as yet somewhat fanciful but we can now reasonably aim to live to about 85 or 90, with few of us dying of disease under the age of 70. If we are to achieve this we have to attack cancers and heart disease, which account for more than half of all life lost under the age of 85, and those few diseases that stand out as special cases. These include diseases associated with the excessive use of alcohol, addictive drugs, motorcycles, cigarette smoking in women and large numbers of sexual partners.

But being healthy is not just a matter of what you do or do not do. It seems that health and long life are often a gift bestowed on a person at conception when they inherit good genes. With the combined effects of healthy habits and good luck many people’s health can be maintained for years with good medical care taking the edge off diseases and accidents. Until fairly recently, living longer usually meant accumulating more and more disorders, diseases and disabilities which, together with social isolation, poverty, failing memory, a loss of purpose, reduced family contacts and other limitations, have led to a vast increase in the numbers of elderly people living out the last years of their lives in residential care. Younger people, seeing this as a depressing future for themselves, are beginning to get concerned-and rightly so. A questionnaire in a Swedish magazine in 1971 asked readers how they most wanted to did A large majority said they wanted to pass away quickly and without worrying. So, ironically, what we are all trying so desperately to prevent-heart disease – appears to be exactly what, in one form, many of those ‘at risk’ most want to die from. But as in the old monk’s prayer-’Dear Lord, give me patience; but give it to me now’-we can’t choose when this sudden and quick form of death will take us. None of us would mind dying like this in our seventies or eighties but the tragedy is that increasing numbers of men in their forties or fifties are losing their lives in this way.

Some people worry about the long-term effects of a population with an ever increasing proportion of ever older people, and they have a point which has to be taken seriously by those who try to prolong life at almost any price. Viewed in the widest possible socio-economic perspective, the gradual move from a three-generation society to a four-generation one is likely to produce increasing strain between the productive and reproductive groups and those who are mainly ‘takers’ from society. Our industrial society cannot find enough jobs for its working-age people, let alone the elderly. So we could soon see countless millions of pensioners in the western world with many years of life to live but with nothing to do.

No one would dispute the benefits preventive medicine has brought in the earliest part of life but, some people are asking, should it be allowed to do the same for the other end of the life scale – at least in those societies where already those who reach middle age tend to live into their eighties? All of this may appear somewhat pessimistic but it could well be that within the reasonably near future the elderly will be taking up so much of the nation’s resources that curative medicine for the productive sector of society will be seriously put at risk. There are those who would say that this is already happening, at least to some extent.

*16/72/5*

Although the time will come in the course of most forms of dementia when sufferers will become less involved with their environment and those around them because of apathy, loss of concentration, and so on, it is best to make the most of what they can achieve while this is still possible. Life will then become fuller not just for the sufferer, but also for those who are involved in caring. This chapter describes some simple activities that may be possible in the early and mid stages of the disease. Rather than trying to keep a person with dementia active all day long, it is probably better to break up the day by organizing several short periods of activity at convenient times. In the earlier stages of the disease it may be helpful to concentrate upon those that will result in the sufferer enjoying a feeling of achievement and of having been useful.

Other important areas that relate to the preservation of independence are the need to stop driving, to give up work, to give up living alone, and often to move house. These will all be discussed in turn.

It is not usually possible for people with dementia to learn new skills so it is best to base activities, whether recreational or otherwise, on skills that have already been obtained in earlier life, taking advantage of them until they fade from the memory store. Activities that involve relationships with other people and pets are often among the most meaningful for a person with a declining intellect. It is also important to remember the need for physical exercise.

This chapter will only be able to provide ideas, as with so many of the other chapters in this book. Trial and error alone will show what is best for an individual and his or her pattern of activity should not be expected to remain unchanged as the months pass.

*99\138\2*

As a dementing illness progresses, relatives and, to a lesser extent, friends have to come to terms with the loss of someone they love. Although this process is a slow one, starting with the realization that the sufferer is not the person he or she used to be, and progressing to a loss of companionship and a hundred and one other losses, it is very much akin to the grief and bereavement experienced after someone has died. Although the body is physically still present, the personality goes. This is particularly painful when the sufferer is unable to communicate with, understand, or recognize you. This sense of loss is very difficult to cope with sometimes, and the long-drawn-out grieving process may affect the pattern of bereavement when the sufferer eventually dies. Just as you come to terms with the situation, your relative may deteriorate in another way and you have to adjust all over again.

With a progressive illness like dementia, the grief can get worse as time goes on and very often death is a merciful release from this type of emotional turmoil, just as it is from the physical burdens and the distressful existence of the sufferer. Many people won’t understand what you are going through. We can all relate to the recently bereaved, but this is a situation that is only really understood by others who have experienced it, either first hand or by working closely with those in your position. As for so many of the emotional problems that arise when caring for a person with dementia, the main anchor in coping with the living bereavement process can only be a sharing of the experience with others. There is little to be gained from keeping a stiff upper lip and maintaining a facade of emotional independence.

*77\138\2*

A young person with suspected dementia will probably first be referred to a neurologist. This is a doctor who has been specially trained in the diagnosis and treatment of disorders of the nervous system, including the brain. Neurologists ensure that a thorough physical examination is undertaken, having carefully inquired into the history of the illness, and will arrange appropriate tests, including blood tests and special X-rays. However, after making a diagnosis, many will not be in a position to offer any regular help and will refer the continuing management of the patient back to the general practitioner.

An older person with dementia is more likely to be referred to a geriatrician or a psychiatrist with a special interest in the elderly, sometimes called a psychogeriatrician. Geriatricians are trained in all the disorders that are found more commonly in older people. They will perform a very similar assessment to that provided by the neurologist for younger people, but will also have access to many of the health service resources that are essential for the continuing care and support for people with dementia, and for their relatives and carers.

As well as hospital beds to provide intermittent relief or holiday admissions the geriatric department usually has a day hospital. This is not necessarily a facility for providing relief for families, but an environment in which further careful assessment can be undertaken. In most cases there has to be a ‘therapeutic’ need for a person to attend a day hospital. Day relief is provided elsewhere, for example at day centres run by the statutory and voluntary services.

Although there are no strict rules, elderly people with dementia who require screening are generally referred first to a geriatrician, but after this the care for those who are mobile as well as demented usually falls to the psychogeriatrician. There are good practical reasons for this; for instance, psychiatric day hospitals are more secure and a wandering demented person is less likely to escape and come to harm. On the other hand a demented person who is heavily dependent on physical nursing will more usually need the help of the geriatric service. There are of course many exceptions to this generalization.

Very often psychogeriatricians will visit patients in their own home, and take the opportunity to familiarize themselves with the problems that relatives and other carers are having to manage. In this way they can judge how best the resources that they have available can help. It also allows those looking after a person with dementia to demonstrate the difficulties they are facing and being able to talk about the problem in their home environment is often easier than trying to describe the situation in a busy out-patient clinic.

Once the matters of diagnosis and assessment have been completed, the specialist will plan the future with the family, the general practitioner, and often other members of his team. It is important that everybody knows about this ‘package’ so that they can see the way ahead. One must also remember that the package has to be regarded flexibly and its provisions may need to be changed as the situation alters.

In some parts of the country there are specialist clinics for people with dementia where a person with dementia isn’t just seen in a slot between people with other conditions, but is assessed in an environment in which all patients have similar problems and all staff are specially trained in this area of medicine. The pattern in different memory clinics varies, but in some every patient is seen by a geriatrician, a psychiatrist, and a psychologist, and great attention is paid to the problems and needs of the carers. (A psychiatrist is a doctor trained in the problems of mental illness; a psychologist, although not medically qualified, is trained in the skills of behaviour assessment, behaviour treatment, and other related activities; he is also able to give valuable advice.) A full appraisal of the medical problems is made, a diagnosis of the underlying disorder is established, and treatment is prescribed for the fortunate few with a treatable underlying condition. The way ahead is mapped out and the patients and their families seen regularly two or three times a year. The day to day management of patients’ care is returned to the general practitioner or to the local specialist if they have been referred from another area of the country. The clinic may also have a support group attached to it for the families of people with dementia who live in the district. The number of clinics like this is increasing and, if one is available locally, your general practitioner will probably seek from it a second opinion. One of the major strengths of such clinics is that they often have a representative of both the geriatric and the psychogeriatric services, allowing closer collaboration between the two in dealing with the needs of a particular person.

*55\138\2*

Multiple infarcts – a series of strokes – are the second most common cause of dementia. Typically a stroke causes paralysis of the limbs and the face on one side of the body, but there are many areas of the brain where a stroke can affect the intellect without leaving any tell-tale outward signs in the rest of the body. In some cases, however, there is a mixture resulting in both physical abnormalities and intellectual difficulties. Occasionally a single large stroke can also cause dementia, but this is less common.

As dementia caused by strokes is a common affliction, and because its progress can sometimes be halted or slowed down, it deserves a chapter of its own. It is a condition that we should all be aware of and on the look-out for.

Although he is usually associated with the condition that now bears his name, Alois Alzheimer also worked in this field. He published a short report while working in an asylum in Frankfurt describing arteriosclerotic changes in the brain which he identified as usually occurring in late middle age. The symptoms and signs that he recorded in his patients are very similar to the picture that we see nowadays although many people with multiple infarct dementia are into their seventies and eighties.

*33\138\2*

The pattern of the symptoms and physical changes in most of the illnesses that cause dementia allows one to divide the progress of the disease into roughly three phases. These are by no means exact and they vary from individual to individual with the same condition, and from disease to disease. Nevertheless they give us a useful rule of thumb and allow us to decide whether a person with dementia is in the early, mid, or late stages of the disease. Each of these phases has a particular message and often these messages are not appreciated by those working in the medical and paramedical professions and the social services.

In the earliest phase of a dementing illness it is essential to ensure that the sufferer is properly investigated for treatable underlying conditions, as already emphasized, having first ascertained that the problems are really caused by dementia and not just by a worse than average memory loss. It is this phase that is often incorrectly accepted by many relatives, friends, and others as normal ageing and what one expects of somebody in their late seventies or early eighties. At this stage the dementia is usually causing significant memory loss, perhaps some disorientation in time, and a tendency to get lost in familiar places. Sufferers may be depressed because of the loss of intellect that they perceive in themselves or they may become irritable as a result of their forgetfulness. Misplaced objects are often considered to have been stolen by others and some difficulty with speech may occur.

The next or middle phase is marked by a deterioration in ability that makes it clear to everybody that something is wrong and that it is no longer a question, even stretching the imagination considerably, that normal ageing is still the problem. This is when significant difficulty in day to day living presents itself. In this stage of the disease people with dementia may be completely unable to cook for themselves, shop, clean the house, or generally look after themselves. Speech becomes even more difficult, and wandering and similar behaviour abnormalities a major problem. This is a stage at which in many cases it becomes apparent to relatives that the individual concerned no longer has the personality they loved, though that person is nevertheless present in a physical sense. This can induce a sense of ‘living bereavement’ which may take years to come to terms with.

In most medical conditions one expects the need for support and involvement of professional people to be greatest towards the end of the disease. It is not so with many of the conditions that cause dementia. It is now, in the middle stages of the disease, that the carers need the greatest amount of support, as it is at this stage that they have the most difficult problems to contend with, both those presented by the sufferer and also those that they themselves begin to experience at an emotional and personal level. These are addressed in later chapters. It is particularly important for doctors especially to be aware of this variation on the normal disease pattern.

The third and final phase that occurs in many cases is one of total dependence, sometimes associated with almost complete inactivity, whether the person who is suffering from dementia is confined to his or her bed or a combination of bed and chair. In many ways this period is met with some feeling of relief by carers. There is no longer the risk of an explosion or a fire from an incorrectly used gas stove, nor the possibility of an accident caused by a tendency to wander out into the road or by falling down stairs. The physical side of the illness becomes more apparent and it is easier for most people to relate to this. In many instances they have looked after a physically dependent person, such as a young child, in the past and caring for a person with dementia in this final phase is in many ways similar to looking after a child. The sad thing of course is that in the case of a child one anticipates that the problem will diminish as the child grows older, whereas in the case of someone with dementia, it is going to get worse.

This account is probably one of the gloomier parts of this book. It has, however, been written for very positive reasons. Uncertainty about the future is one of the major problems with which those caring for people with dementia have to contend. Many of those involved in a professional capacity in providing advice and support are loath to explain about the future, often because they themselves find it too difficult to give relatives and other carers a full picture of what lies ahead of them. However, with the increasing acceptance of psychiatric illness as a physical problem like the malfunction of any other organ in the body, disorders of the brain, particularly the dementias, are increasingly discussed in the popular media and in casual conversation. Piecemeal and anecdotal accounts are often more frightening than having the matter carefully explained in the context of the help and support available. It is impossible to come to terms with and plan for the future if one doesn’t know what the future holds. Unhappy though the picture is, it will be seen as the reader progresses that there is an enormous amount of support available, and also a lot that an individual carer can do to help him- or herself to cope with the stresses and strains that will arise, and at the same time to help the person suffering from dementia to have as pleasant and full a life as is possible.

Many people caring for someone suffering from dementia want to know how long the disease will take to run its course. This is a difficult question to answer and it is almost impossible to fix a definite span to each of the three stages described. In most cases, however, the disease processes will run their course over a period of about five to seven years. Since it is often not appreciated that elderly people have a dementing illness when the disease is in its earliest stages, they may already be one or two years into the progression of their illness before the diagnosis is made. This means of course that the disease will appear to last for a shorter period.

In younger people, especially those under sixty, the disease often runs a more rapid course and may be two or three years less in duration. Even so, the disease may appear to last longer as it is often less likely that in younger people the early stages will be mistaken for anything other than something abnormal, whereas if the same symptoms had become apparent twenty years later, they might well have been mistaken for the changes of normal ageing.

*11\138\2*